HHS Public Access Author manuscript Author Manuscript
BMJ Qual Saf. Author manuscript; available in PMC 2017 May 01. Published in final edited form as: BMJ Qual Saf. 2016 May ; 25(5): 372–378. doi:10.1136/bmjqs-2015-004081.
Environmental Factors and their Association with Emergency Department Hand Hygiene Compliance: an Observational Study Eileen J. Carter, PhD, RN1,2,*, Peter Wyer, MD3, James Giglio, MD3, Haomiao Jia, PhD1,4, Germaine Nelson, RN, MSN, MBA, CEN2, Vepuka E. Kauari, RN, MSN, CEN2, and Elaine L. Larson, PhD, RN, FAAN, CIC1,4 1Columbia
University School of Nursing, New York, NY, USA
Author Manuscript
2NewYork-Presbyterian
Hospital, New York, NY, USA
3Columbia
University Medical Center/ NewYork-Presbyterian Hospital, New York, NY, USA
4Columbia
University Mailman School of Public Health, New York, NY, USA
Abstract Objectives—Hand hygiene is effective in preventing healthcare-associated infections. Environmental conditions in the emergency department (ED), including crowding and the use of nontraditional patient care areas (i.e. hallways), may pose barriers to hand hygiene compliance. We examined the relationship between these environmental conditions and proper hand hygiene.
Author Manuscript
Methods—This was a single-site, observational study. From October 2013 to January 2014, trained observers recorded hand hygiene compliance among staff in the ED according to the World Health Organization “My 5 Moments for Hand Hygiene.” Multivariable logisitic regression was used to analyze the relationship between environmental conditions and hand hygiene compliance, while controlling for important covariates (e.g., hand hygiene indication, glove use, shift, etc.). Results—A total of 1,673 hand hygiene opportunities were observed. In multivariable analyses, hand hygiene compliance was significantly lower when the ED was at its highest level of crowding than when the ED was not crowded and lower among hallway care areas than semi-private care areas (OR=0.39, 95% CI 0.28-0.55; OR= 0.73, 95% CI 0.55-0.97).
Author Manuscript
Conclusions—Unique environmental conditions pose barriers to hand hygiene compliance in the ED setting and should be considered by ED hand hygiene improvement efforts. Further study is needed to evaluate the impact of these environmental conditions on actual rates of infection transmission. Keywords handwashing; infection control; guideline adherence; emergency medical services
Corresponding Author Eileen J. Carter, Columbia University School of Nursing, 617 West 168th Street, New York, NY 10032, Phone: 347-886-2173, Fax: 212-305-3659, [email protected].
*
Carter et al.
Page 2
Author Manuscript
INTRODUCTION Hand hygiene is a leading means to prevent healthcare-associated infections.[1-3] Proper hand hygiene is particularly important in the emergency department (ED) as the ED is a major site of healthcare delivery, admitting approximately half of all hospital inpatients,[4] and is a frequent setting of the placement of invasive devices, which are subject to infection. While studies have consistently found that environmental conditions,[5] such as the availability of sinks and alcohol-based hand sanitizers impact hand hygiene compliance in the inpatient setting, little is known of the role of environmental factors on hand hygiene practices in the ED.[6]
Author Manuscript
Environmental conditions unique to the ED may pose barriers to recommended infection prevention practices. To expedite patient care when treatment rooms are full, EDs provide care in nontraditional areas such as hallways,[7] a practice found to be predictive of lower hand hygiene compliance.[6] Crowding, “a situation in which the identified need for emergency services outstrips available resources in the ED”[8, 9] is another common condition of EDs.[10] While ED crowding is associated with several aspects of poor care quality,[11] its relationship with hand hygiene compliance is unknown. To adequately address the challenge of ED crowding, it is important to understand ED crowding's consequences, not only in terms of efficiency of care processes, but also on clinical quality and outcomes of care. Using observational methods, we examined the relationship between environmental factors and hand hygiene compliance in the ED.
METHODS Author Manuscript
This was part of a single-site observational investigation examining the relationship between ED crowding and healthcare workers’ compliance with infection prevention practices (i.e. hand hygiene during routine patient care and aseptic technique during the insertion of urinary catheters, central venous catheters and peripheral venous catheters). Here, we report hand hygiene compliance findings. Prior to study commencement, we informed staff of the research via email and shift huddles and reported that we were examining the relationship between ED crowding and different processes of care.
Author Manuscript
This investigation was conducted from October 2013 to January 2014 in a high-volume ED in the New York metropolitan area of the United States. Hand hygiene compliance was observed during 20-60 minute observation periods through direct observation. Four trained research associates observed hand hygiene compliance according to the World Health Organization's (WHO) “My 5 Moments for Hand Hygiene.”[12]. Research associates were trained using publicly available WHO hand hygiene training materials[12] and engaged in inter-rater reliability testing prior to data collection and monthly over the course of the study period, in which a series of hand hygiene practices were co-observed in the study ED. Interrater agreement was formally tested using Cohen's Kappa and disagreements were discussed and resolved according to WHO hand hygiene training tools.[1] Research associates observed hand hygiene compliance among nurses, physicians, nursing assistants, and “other,” defined as respiratory therapists, radiology technicians, security, and
BMJ Qual Saf. Author manuscript; available in PMC 2017 May 01.
Carter et al.
Page 3
Author Manuscript
environmental service personnel in the adult ED. Research associates only marked if hand hygiene was performed; hand hygiene technique was not evaluated. Observations were conducted unobtrusively from hallway vantage areas and research associates did not interfere with patient care to observe hand hygiene practices. Psychiatric and pediatric areas of the ED were excluded. No observations were conducted among healthcare workers providing care to psychiatric patients in the adult ED or among emergency situations (e.g. cardiac arrest). To limit the overrepresentation of individual practices, observers recorded a maximum of three hand hygiene opportunities per healthcare worker during an observation period.
Author Manuscript
Research associates recorded the following variables potentially associated with hand hygiene compliance:[1, 6] healthcare worker type, glove use, nursing staffing levels, day of the week, shift of observation (day or night), hand hygiene indication, location of patient receiving care and ED crowding. Variables were recorded using a modified WHO data collection tool (Appendix). Hand hygiene indications were specified according to the WHO “My 5 Moments for Hand Hygiene,” i.e. before patient contact, before an aseptic/clean procedure, after patient contact, after body fluid exposure, and after contact with the patient's environment.[12]
Author Manuscript
Patient care locations were recorded as ‘private,’ ‘semi-private’ or ‘hallway.’ We defined ‘private’ areas as patient care spaces equipped with doors, ‘semi-private’ areas as patient care spaces partitioned by curtains and ‘hallway’ areas as those located in corridors. To quantify ED crowding, we used the National Emergency Department Overcrowding Scale (NEDOCS),[13] a seven-item validated tool that takes into account census, timeliness of care, patient acuity and institutional constraint information. Crowding data were obtained from the ED tracking system and nurses in ED supervisory roles (e.g., nurse managers, charge nurses). Upon completion of an observation period, crowding data were entered into the NEDOCS calculator[14] to determine an overall ED crowding score for each observation period. No identifying information was collected among healthcare workers or patients over the course of the study and the medical center's institutional review board approved the study with a waiver of informed consent. Data Analysis
Author Manuscript
Our outcome of interest was hand hygiene compliance for each hand hygiene opportunity. First, we linked ED crowding scores to the hand hygiene compliance data of its observation period, analyzed data using descriptive statistics and recoded continuous variables into categorical level data based on their distribution. We classified NEDOCS crowding scores, which range from 0-200, into categories designated by the NEDOCS instrument.[13] Specifically, we defined NEDOCS
BMJ Qual Saf. Author manuscript; available in PMC 2017 May 01. Published in final edited form as: BMJ Qual Saf. 2016 May ; 25(5): 372–378. doi:10.1136/bmjqs-2015-004081.
Environmental Factors and their Association with Emergency Department Hand Hygiene Compliance: an Observational Study Eileen J. Carter, PhD, RN1,2,*, Peter Wyer, MD3, James Giglio, MD3, Haomiao Jia, PhD1,4, Germaine Nelson, RN, MSN, MBA, CEN2, Vepuka E. Kauari, RN, MSN, CEN2, and Elaine L. Larson, PhD, RN, FAAN, CIC1,4 1Columbia
University School of Nursing, New York, NY, USA
Author Manuscript
2NewYork-Presbyterian
Hospital, New York, NY, USA
3Columbia
University Medical Center/ NewYork-Presbyterian Hospital, New York, NY, USA
4Columbia
University Mailman School of Public Health, New York, NY, USA
Abstract Objectives—Hand hygiene is effective in preventing healthcare-associated infections. Environmental conditions in the emergency department (ED), including crowding and the use of nontraditional patient care areas (i.e. hallways), may pose barriers to hand hygiene compliance. We examined the relationship between these environmental conditions and proper hand hygiene.
Author Manuscript
Methods—This was a single-site, observational study. From October 2013 to January 2014, trained observers recorded hand hygiene compliance among staff in the ED according to the World Health Organization “My 5 Moments for Hand Hygiene.” Multivariable logisitic regression was used to analyze the relationship between environmental conditions and hand hygiene compliance, while controlling for important covariates (e.g., hand hygiene indication, glove use, shift, etc.). Results—A total of 1,673 hand hygiene opportunities were observed. In multivariable analyses, hand hygiene compliance was significantly lower when the ED was at its highest level of crowding than when the ED was not crowded and lower among hallway care areas than semi-private care areas (OR=0.39, 95% CI 0.28-0.55; OR= 0.73, 95% CI 0.55-0.97).
Author Manuscript
Conclusions—Unique environmental conditions pose barriers to hand hygiene compliance in the ED setting and should be considered by ED hand hygiene improvement efforts. Further study is needed to evaluate the impact of these environmental conditions on actual rates of infection transmission. Keywords handwashing; infection control; guideline adherence; emergency medical services
Corresponding Author Eileen J. Carter, Columbia University School of Nursing, 617 West 168th Street, New York, NY 10032, Phone: 347-886-2173, Fax: 212-305-3659, [email protected].
*
Carter et al.
Page 2
Author Manuscript
INTRODUCTION Hand hygiene is a leading means to prevent healthcare-associated infections.[1-3] Proper hand hygiene is particularly important in the emergency department (ED) as the ED is a major site of healthcare delivery, admitting approximately half of all hospital inpatients,[4] and is a frequent setting of the placement of invasive devices, which are subject to infection. While studies have consistently found that environmental conditions,[5] such as the availability of sinks and alcohol-based hand sanitizers impact hand hygiene compliance in the inpatient setting, little is known of the role of environmental factors on hand hygiene practices in the ED.[6]
Author Manuscript
Environmental conditions unique to the ED may pose barriers to recommended infection prevention practices. To expedite patient care when treatment rooms are full, EDs provide care in nontraditional areas such as hallways,[7] a practice found to be predictive of lower hand hygiene compliance.[6] Crowding, “a situation in which the identified need for emergency services outstrips available resources in the ED”[8, 9] is another common condition of EDs.[10] While ED crowding is associated with several aspects of poor care quality,[11] its relationship with hand hygiene compliance is unknown. To adequately address the challenge of ED crowding, it is important to understand ED crowding's consequences, not only in terms of efficiency of care processes, but also on clinical quality and outcomes of care. Using observational methods, we examined the relationship between environmental factors and hand hygiene compliance in the ED.
METHODS Author Manuscript
This was part of a single-site observational investigation examining the relationship between ED crowding and healthcare workers’ compliance with infection prevention practices (i.e. hand hygiene during routine patient care and aseptic technique during the insertion of urinary catheters, central venous catheters and peripheral venous catheters). Here, we report hand hygiene compliance findings. Prior to study commencement, we informed staff of the research via email and shift huddles and reported that we were examining the relationship between ED crowding and different processes of care.
Author Manuscript
This investigation was conducted from October 2013 to January 2014 in a high-volume ED in the New York metropolitan area of the United States. Hand hygiene compliance was observed during 20-60 minute observation periods through direct observation. Four trained research associates observed hand hygiene compliance according to the World Health Organization's (WHO) “My 5 Moments for Hand Hygiene.”[12]. Research associates were trained using publicly available WHO hand hygiene training materials[12] and engaged in inter-rater reliability testing prior to data collection and monthly over the course of the study period, in which a series of hand hygiene practices were co-observed in the study ED. Interrater agreement was formally tested using Cohen's Kappa and disagreements were discussed and resolved according to WHO hand hygiene training tools.[1] Research associates observed hand hygiene compliance among nurses, physicians, nursing assistants, and “other,” defined as respiratory therapists, radiology technicians, security, and
BMJ Qual Saf. Author manuscript; available in PMC 2017 May 01.
Carter et al.
Page 3
Author Manuscript
environmental service personnel in the adult ED. Research associates only marked if hand hygiene was performed; hand hygiene technique was not evaluated. Observations were conducted unobtrusively from hallway vantage areas and research associates did not interfere with patient care to observe hand hygiene practices. Psychiatric and pediatric areas of the ED were excluded. No observations were conducted among healthcare workers providing care to psychiatric patients in the adult ED or among emergency situations (e.g. cardiac arrest). To limit the overrepresentation of individual practices, observers recorded a maximum of three hand hygiene opportunities per healthcare worker during an observation period.
Author Manuscript
Research associates recorded the following variables potentially associated with hand hygiene compliance:[1, 6] healthcare worker type, glove use, nursing staffing levels, day of the week, shift of observation (day or night), hand hygiene indication, location of patient receiving care and ED crowding. Variables were recorded using a modified WHO data collection tool (Appendix). Hand hygiene indications were specified according to the WHO “My 5 Moments for Hand Hygiene,” i.e. before patient contact, before an aseptic/clean procedure, after patient contact, after body fluid exposure, and after contact with the patient's environment.[12]
Author Manuscript
Patient care locations were recorded as ‘private,’ ‘semi-private’ or ‘hallway.’ We defined ‘private’ areas as patient care spaces equipped with doors, ‘semi-private’ areas as patient care spaces partitioned by curtains and ‘hallway’ areas as those located in corridors. To quantify ED crowding, we used the National Emergency Department Overcrowding Scale (NEDOCS),[13] a seven-item validated tool that takes into account census, timeliness of care, patient acuity and institutional constraint information. Crowding data were obtained from the ED tracking system and nurses in ED supervisory roles (e.g., nurse managers, charge nurses). Upon completion of an observation period, crowding data were entered into the NEDOCS calculator[14] to determine an overall ED crowding score for each observation period. No identifying information was collected among healthcare workers or patients over the course of the study and the medical center's institutional review board approved the study with a waiver of informed consent. Data Analysis
Author Manuscript
Our outcome of interest was hand hygiene compliance for each hand hygiene opportunity. First, we linked ED crowding scores to the hand hygiene compliance data of its observation period, analyzed data using descriptive statistics and recoded continuous variables into categorical level data based on their distribution. We classified NEDOCS crowding scores, which range from 0-200, into categories designated by the NEDOCS instrument.[13] Specifically, we defined NEDOCS
